How effective is Indigenous cultural safety and anti-bias training at improving patient experience?

Researchers from Unity Health Toronto led a first-of-its kind trial in which Indigenous actors were trained to perform as patients and evaluate health care providers who completed intensive and brief Indigenous cultural safety trainings.

This innovative randomized clinical trial led by researchers at the Well Living House Action Research Center sought to evaluate the impact of an intensive Indigenous cultural safety training (ICS) and brief anti-bias training, compared to standard medical education.

Research shows that health care services routinely fail Indigenous populations, including in affluent countries such as Canada. Recommendations for improving health care for Indigenous communities often include specific training for clinicians on how to provide better care for Indigenous patients.

The Truth and Reconciliation Commission (TRC) calls on Canada to address the poor health outcomes among Indigenous communities, in part by providing cultural competency training for all health care professionals. However, there is limited evidence of the effectiveness of specific content and approaches to cultural safety training for health care professionals—particularly with respect to whether or not these trainings have positive impacts for patients.

The researchers found that the tested anti-bias training and Indigenous cultural safety trainings have the potential to substantially improve patient experience and patient recommendations of clinicians. They also showed that using trained actors to serve as "secret shoppers" and evaluate health care providers is a feasible method of evaluating patient focused impacts of anti-bias training.

This trial demonstrates a novel, patient-oriented approach to understanding the effects of anti-bias training, said Dr. Janet Smylie, family physician and Tier 1 Canada Research Chair at St. Michael's Hospital and the University of Toronto.

"There has been good uptake of TRC recommendations to implement Indigenous cultural safety training for health care providers and trainees—resulting in rapid growth of a diversity of courses," said Smylie. "Despite all the new training, reports of inappropriate care of Indigenous patients leading to preventable harms is unfortunately still very common."

"The problem is trying to figure what type of training will actually make a positive difference for Indigenous patients. There is commonly a disconnect between clinician self-assessment and what Indigenous patients are actually experiencing."

Dr. William Cox, a co-author of the study with the organization Inequity Agents of Change, said feelings of safety are essential when thinking about the relationship between patients and doctors, particularly when it comes to Indigenous patients.

"A patient is in a vulnerable state, and needs to feel safe in their doctor's care. We know that Indigenous people often do not feel safe working with the largely White medical establishment, and we need evidence-based solutions to this issue. This research study is a huge and exciting step in that direction," Cox said.

"Crucial to the testing of any diversity intervention is its real-world impact. In the context of this study, our question of impact would be, "When medical professionals have received training, do their Indigenous patients feel safer?" This question led to one of the most innovative and exciting components of this study, its methodology involving standardized patients."

Actors trained to complete unannounced Indigenous standardized patient visits

The randomized controlled trial, led by Smylie and partners from the University of Wisconsin and San'yas, had three arms. The first arm included clinicians randomized to complete the intensive eight to 10-hour San'yas Anti-Racism Indigenous Cultural Safety Training course for health care providers.

The second arm included clinicians randomized to complete a previously demonstrated brief one-hour anti-bias training adapted to address anti-Indigenous bias. The third arm, the control arm, included clinicians who completed their standard continuing medical education (CME) and did not take specific anti-bias or Indigenous cultural safety training until after study completion.

Over the past several years, Unity Health Toronto staff and physicians have also taken the San'yas Anti-Racism Indigenous Cultural Safety Training course separately from this research.

The participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners who worked in family practice clinics and the emergency department in four different teaching hospitals in Toronto.

Nine Indigenous actors were trained to perform as Indigenous patients and complete unannounced Indigenous standardized patient visits (UISP). As part of the UISP, the actors were trained to seek care from the participating clinicians for a type of arthritis.

During the UISP, the patient requested a prescription renewal for an anti-inflammatory medication. After the UISP, these actors scored their overall patient experience and also clinical practices for prescription of anti-inflammatory medications and pain assessment.

Throughout the trial, none of the participating clinicians detected that the actors were not real patients.

The primary outcomes of the trial included overall patient experience, the proportion of clinicians who would be highly recommended by the patient, the medication renewal, and physician pain management scores.

The trial found that clinicians in the intensive and brief ICS arms were six to eight times more likely to be highly recommended to friends or family members compared those in the control group. Overall patient experience scores were also significantly higher for those in the intensive and brief ICS arms compared to control. The trial did not detect differences in clinical prescribing and pain assessment practices.

The authors concluded that the trial demonstrated that UISPs are a feasible and effective tool to measure the impacts of ICS training or anti-bias training and that the tested intensive and brief ICS trainings hold promise to substantially improve Indigenous patient experience. A larger study is needed to determine the impact on clinical practice.

"We know Indigenous people have significant gaps in health access and health outcomes resulting from centuries of intensive dehumanization and policies intended to marginalize and exclude Indigenous people, and we must address this," said Dr. Suzanne Shoush, a First Nations/Black family physician who works at Unity Health Toronto as the Physician Lead, Indigenous Wellbeing, Reconciliation, and Partnerships and is also the Indigenous Health Faculty lead with the Department of Family and Community Medicine with the University of Toronto.

"Indigenous people are dying because they are not receiving the care that medical experts are supposed to be identifying and providing, but are not. Indigenous cultural safety training is a specific and critical skill that will allow us to make a difference in health care," she added.

"This research is critical in demonstrating the positive patient impact when physicians receive proper training that allows them to provide truly, holistically expert medical care that makes a difference in outcomes for patients and communities."